The chief medical consultant of the Blood Transfusion Service Board did not advise staff or the board of the BTSB which heat treatment should be applied in the manufacture of blood products for haemophiliacs even though he knew of one method which was deemed to be safe.
The heat treatment adopted by the BTSB to deactivate viruses in its Factor 9 blood-clotting agent failed to prevent the transmission of hepatitis C to at least four people, three of them children, the tribunal heard.
Dr Terry Walsh, who was chief medical consultant with the BTSB when the board recommenced making Factor 9 in mid-1988 from raw material returned to it by the Armour pharmaceutical company, admitted yesterday that he did not check to see if the product had been heat-treated at 80 degrees for 72 hours.
It emerged that he had been informed at a meeting in October 1986 that this had proved to be an effective method of preventing transmission in the UK of non-A, non-B hepatitis, which later became known as hepatitis C.
Dr Walsh said he was not an expert in the area and his concern at the time was that the board would be in a position to supply products which were acceptable to the people who used them.
He said he believed the heat treatment applied by the BTSB was the same as that applied by Travenol Laboratories, but at this point he could not recall the temperature used or the length of time Travenol had allowed for heat-treating its products.
Documents opened to the tribunal showed that the heat treatment agreed with Travenol was notified to Dr Walsh in January 1987 as 60 degrees Celsius for 72 hours. However, it may have changed between then and 1988, as notes recorded by Ms Cecily Cunningham, the board's then chief biochemist, showed that from February 1988 she was using a heat treatment of 60.6 degrees in air for 152 hours.
Counsel for the Irish Haemophilia Society, Mr John Trainor SC, put it to Dr Walsh that the system of heat treatment used by the board had led to a BTSB batch of Factor 9 infecting four people, two of them the children of a woman who has already given evidence to the tribunal using the pseudonym Felicity.
"From all the evidence, if the product they received had been heat-treated at 80 degrees for 72 hours, that would not have happened, and these children would not have to go through what they did", Mr Trainor suggested.
Dr Walsh replied that the heat treatment provided by the BTSB was acceptable to doctors treating haemophiliacs. "If the user had required heat treatment of 80 degrees for 72 hours, it would certainly have been given consideration", he said.
Mr Trainor put it to Dr Walsh that, as chief medical consultant, the buck stopped with him. He had a duty to inform the board of the heat treatment he knew to be safe and instruct the board's technical staff to implement it.
Dr Walsh did not accept that the buck stopped with him. His duty was to advise the board of the BTSB, which was at liberty to seek advice from other sources.